What are the management strategies for ischemic and hemorrhagic stroke?

Management of Ischemic and Hemorrhagic Stroke

The management of ischemic and hemorrhagic strokes requires distinct treatment approaches based on stroke type, with immediate neuroimaging being essential for differentiation and both types requiring specialized stroke unit care to optimize outcomes for morbidity, mortality, and quality of life.

Initial Assessment and Differentiation

• Urgent neuroimaging with non-contrast CT (NCCT) is mandatory to differentiate between ischemic and hemorrhagic stroke before initiating treatment 1
• CT angiography (CTA) should be performed immediately after NCCT in patients with suspected acute ischemic stroke who arrive within 6 hours and are potentially eligible for endovascular thrombectomy (EVT) 2
• Rapid initial evaluation of airway, breathing, and circulation (ABCs) should be performed immediately upon arrival for all stroke patients 3
• All patients with suspected stroke should undergo ECG to assess cardiac rhythm, though this should not delay assessment for thrombolysis 1

Acute Ischemic Stroke Management

Thrombolytic Therapy

• Eligible patients should receive intravenous alteplase (rtPA) as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes 1
• Standard dosing for alteplase is 0.9 mg/kg to a maximum of 90 mg total dose, with 10% given as an intravenous bolus over one minute and the remaining 90% given as an intravenous infusion over 60 minutes 1
• Blood pressure must be controlled below 185/110 mmHg before rtPA administration and maintained below 180/105 mmHg for at least 24 hours after treatment 2
• The most recent evidence suggests that intravenous alteplase administered 4.5 to 24 hours after onset in patients with salvageable brain tissue identified by perfusion imaging can provide functional benefit, despite an increase in symptomatic intracranial hemorrhage 4

Endovascular Thrombectomy (EVT)

• EVT is indicated for patients with large vessel occlusions, including those who have received intravenous alteplase and those who are not eligible for intravenous alteplase 1
• A validated triage tool (such as ASPECTS) should be used to rapidly identify patients who may be eligible for EVT treatment 2
• Advanced CT imaging such as CT perfusion or multiphase/dynamic CTA can be considered to aid patient selection for EVT, but should not substantially delay treatment 2

Antithrombotic Therapy

• Oral aspirin (325 mg initial dose) is recommended within 24-48 hours after stroke onset for patients not receiving thrombolysis 1
• Aspirin should not be administered within 24 hours of rtPA treatment 5
• Early administration of intravenous aspirin in patients with acute ischemic stroke treated with alteplase does not improve outcome at 3 months and increases the risk of symptomatic intracranial hemorrhage 5
• The usefulness of urgent anticoagulation in patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke is not well established 2
• Urgent anticoagulation, with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke, is not recommended 2

Blood Pressure Management

• For ischemic stroke patients eligible for thrombolytic therapy: Very high blood pressure (greater than 185/110 mm Hg) should be treated concurrently with thrombolysis 2
• For ischemic stroke patients not eligible for thrombolytic therapy: Treatment of hypertension should not be routinely administered 2
• Extreme blood pressure elevation (e.g., SBP > 220 mm Hg or DBP > 120 mmHg) should be treated to reduce the blood pressure by approximately 15%, and not more than 25%, over the first 24 hours 2
• Avoid rapid or excessive lowering of blood pressure as this might exacerbate existing ischemia 2

Acute Hemorrhagic Stroke Management

Blood Pressure Management

• For ICH patients presenting with systolic blood pressure between 150 and 220 mm Hg without contraindications to acute BP treatment, acute lowering of systolic BP to 140 mm Hg is safe and can improve functional outcomes 3
• Blood pressure should be assessed on initial arrival to the ED and every 15 minutes until stabilized 3

Management of Coagulopathy

• Patients with severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets 3
• Patients whose INR is elevated due to vitamin K antagonists should have their medication withheld, receive therapy to replace vitamin K-dependent factors, correct the INR, and receive intravenous vitamin K 3

Surgical Considerations

• Patients with cerebellar hemorrhage who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible 3
• Neurosurgical consultation should be obtained promptly for evaluation of potential surgical interventions 3

Management of Cerebral Edema and Increased Intracranial Pressure

• Surgical decompression and evacuation of large cerebellar infarctions causing brain stem compression and hydrocephalus is recommended 1
• Osmotherapy and hyperventilation are recommended for patients deteriorating due to increased intracranial pressure 1
• Corticosteroids are not recommended for managing cerebral edema and increased intracranial pressure following ischemic stroke 1
• Maintenance fluid management in patients with acute hemispheric or cerebellar strokes includes the use of isotonic saline and the avoidance of hypo-osmolar fluids 2

Supportive Care for Both Stroke Types

Temperature Management

• Normothermia is preferred, with treatment recommended for temperatures >37.5°C 2
• Development of early fever after a hemispheric or cerebellar stroke warrants complete assessment for an infectious or a drug-induced cause 2

Glucose Management

• Hyperglycemia is associated with increased edema in patients with cerebral ischemia and with an increased risk of hemorrhagic transformation 2
• Hypoglycemia (blood glucose <60 mg/dL) should be treated, with a goal to achieve normoglycemia, and hyperglycemia should be treated to achieve blood glucose levels in a range of 140 to 180 mg/dL 1

Prevention of Complications

• Patients should have intermittent pneumatic compression for prevention of venous thromboembolism beginning the day of hospital admission 3
• A formal screening procedure for dysphagia should be performed before initiating oral intake to reduce the risk of pneumonia 3
• Early mobilization is strongly recommended to prevent complications 1

Rehabilitation and Long-term Outcomes

• Comprehensive stroke unit care with specialized rehabilitation should be initiated as early as medically possible 1
• Both ischemic and hemorrhagic stroke patients can achieve similar functional outcomes with appropriate rehabilitation, despite their different pathophysiologies 6, 7
• Management of modifiable risk factors including blood pressure and cholesterol is essential for secondary prevention 1

Clinical Pearls and Pitfalls

• Early deterioration is common in the first few hours after ICH onset, with over 20% of patients experiencing a decrease in GCS of 2 or more points between prehospital assessment and initial ED evaluation 3
• Hematoma expansion occurs in 30-40% of ICH patients and is a predictor of poor outcome; risk factors include presence of contrast extravasation ("spot sign"), early presentation, anticoagulant use, and initial hematoma volume 3
• Diagnostic tests should not delay imaging or treatment decisions 3
• Blood pressure targets may be challenging to achieve and require careful monitoring and aggressive management 3
• Telemedicine/teleradiology evaluations of AIS patients can be effective for correct IV alteplase eligibility decision making when in-house expertise is not available 2